Critical Test Results Management: The Human Touch

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 - doctor and patient

Critical test results management (CTRM) cuts to the heart of the healthcare business. U.S. hospitals complete approximately 12 billion radiology, laboratory and cardiology tests every year. Most are negative and don’t require follow up by the referring clinician. But a handful of test results, amounting to about 1 to 5 percent of a hospital’s test volume, are abnormal or critical. Hospitals have a legal, ethical and moral obligation to ensure that these results are communicated to the responsible physician or patient care team—and IT systems are now closing that loop.

Traditional systems to communicate and manage critical results are full of flaws. There is the manual phone call approach, but phones aren’t always answered or the wrong person might answer the phone. In many hospitals, contact information changes on a regular basis, and radiology departments may not have the correct information. Faxes can be equally problematic as the receiving machine might be off or out of paper. And once communicated, the right person might not receive the fax right away. Unfortunately, it’s not unheard of for it to take days for a radiologist to track the correct physician for results communication.

The problem takes its toll in a number of ways. For starters, hospitals must wrangle with legal and regulatory challenges. “Miscommunication of findings is a causative factor in 85 percent of radiology lawsuits,” reports Tom White, founder of Veriphy. And The Joint Commission (JC) set national patient safety as one of its top goals and requires hospitals to improve processes.

The flip side of the coin is productivity. Every day, radiologists, cardiologists and lab techs make two to three million calls to communicate test results, which can gobble an hour out of the work day for some highly paid specialists.

CTRM systems present a new paradigm. They tap into IT to streamline and automate the results communication process. Solutions not only improve patient safety, but also increase productivity among radiologists and other specialists. It’s a match made in heaven. Here’s how CTRM works.

The CTRM/workflow equation

One option in the CTRM market is Amicas’ RadStream workflow engine. Developed by the radiology department at Cincinnati Children’s Hospital in Ohio, RadStream is designed to address two key issues in radiology: improving critical results notification and reducing interruptions to workflow. The system meets its objectives, says Mark Halsted, MD, RadStream project leader and chief of the Radiology Informatics Research Core at Cincinnati Children’s Hospital.

A pre- and post-implementation analysis conducted by the College of Business at University of Cincinnati showed that Cincinnati Children’s Hospital radiologists conveyed and documented results in 5 percent of cases prior to RadStream. After deployment, notification and documentation jumped by an additional 15 percent without worsening workflow or increasing turnaround time.

The system works by removing the burden of communication from radiologists, and instead, placing responsibility for communication on human operators.

RadStream covers a number of common scenarios. If a referring physician orders a STAT study, RadStream automatically routes the results to a bank of operators via the internet. The first available operator opens the case and communicates the impression or full report to the ordering physician via the phone. The process differs slightly for any case with a critical finding. When a radiologist detects a critical finding, he or she can instant message an operator within the RadStream system. The operator phones the referring physician to bring him or her up to speed before connecting the radiologist and clinician. A final option covers cases where the referring physician may miss a finding such as a subtle pneumonia in an ED patient. In these cases, the radiologist routes the dictation to the operator, who, in turn, ensures that that clinician reads the report. In all cases, the operator documents the connection in a permanent record.

“Human interaction is key to the success of critical test results management,” asserts Halsted. Cincinnati Children’s Hospital taps into file room workers, transcriptionists and radiology extenders to monitor RadStream web interfaces and connect with physicians. “Anything less than human intervention can lead to suboptimal patient care,” he continues. Consider a recent case in which an operator insisted that a nurse physically bring a physician to the phone for a report of a misplaced line that required immediate attention. “An automated system or an overburdened radiologist might not have approached the situation with the same diligence, which could have led to a different result for the patient,” notes Halsted. The other major benefit associated with RadStream is efficiency; since deploying RadStream, radiology report turnaround time plummeted by 50 percent at Cincinnati Children’s Hospital.

Another RadStream user, St. Mary’s Hospital in Athens, Ohio, turned to the workflow engine because radiologists felt they needed a system to document results communication. In the last few years, several referring physicians had claimed in lawsuits they hadn’t received results. Workflow was another challenge, says PACS Administrator Brian Duncan, as radiologists complained about spending too much time trying to locate physicians. RadStream provides a perfect fit. It removes the burden of communication from radiologists without changing the way they work. The radiologist simply marks a study as critical, and file room clerks who monitor the worklist communicate the results to the appropriate physician. The system also records communication to provide a permanent record of results communication.

Managing traffic flow

Like all hospitals nationwide, North Shore Medical Center in Salem, Mass., grapples with JC requirements—particularly a recent ruling that calls for acknowledgement of critical results. The conventional process of reporting results via fax or phones lacks an audit trail. In 2006, the medical center decided to invest in a new approach and deployed Nuance Veriphy CTRM solution.

“Veriphy focuses on the 5 percent of results that need follow up,” says Barbara Corning-Davis, enterprise clinical imaging manager. “It closes the communication loop and ensures that results don’t fall through the cracks.”

The color-coded system divides critical results into three categories: red, orange and yellow. A red, or life-threatening, result requires a one-hour response from the ordering physician. An orange, or critical, finding such as a new fracture requires an 18-hour response. And less critical results such as suggested malignancies are coded yellow and require follow up. “Our radiologists like the system because it confirms that the ordering physician has received results,” says Corning-Davis. “The system is also popular with referring physicians because it helps them better manage their time. A simple glance lets them know if a result requires immediate follow up.”

University of Colorado Hospital in Denver turned to Veriphy late in 2007 after a traumatic year during which the radiology department moved, installed a new PACS and upgraded the RIS.

“We wanted to alleviate the pressure on radiologists,” says PACS Administrator Michael Cain. “It had become very difficult for them to track the correct person for results. Plus, most radiologists are not very good at documenting communication of results.” Veriphy addresses two challenges; it automates the documentation process and it changes the culture among referring physicians by forcing them to listen to messages. The hospital adapted the software to divide findings into two categories: critical results (pertaining to loss of life, limb or eyesight) must be communicated within an hour and significant findings that require attention, but can wait for several hours or longer. Since installing the system, the hospital also has seen radiologists’ productivity increase because they need to spend less time on the phone communicating results.

The power of integration

Integration between CTRM systems and other information systems can boost the utility of an implementation. North Shore Medical Center aims to integrate Veriphy with its EMR to further streamline processes and align radiology communication with lab results notification. At University of Colorado Hospital, Veriphy is integrated with PACS, which means the radiologist simply switches to a Veriphy window if he or she detects a critical finding. After typing in the patient’s name or record number, the radiologist records a message to send to the referring physician according to the preferred means of contact. A permanent log with physicians’ name and date is maintained in the system. The hospital plans to integrate the CTRM software with its voice recognition platform in the future. The integration will save keystrokes as the radiologist can initiate the call without retyping the patient’s name or record number.

IT-lite

Unlike many radiology projects, CTRM is an IT featherweight. RadStream is built to run as independent software; it pulls data from the RIS and runs on existing workstations. In addition to running as a stand-alone solution, RadStream can be embedded into any PACS.

“Veriphy is an IT dream project,” claims Corning-Davis. The CTRM system requires no IT infrastructure. Data are stored offsite. IT did integrate Veriphy with its pager system for pager forwarding, but the process was quite straightforward.

The only other pre-deployment needs are training and education. A five-minute overview of the system suffices for radiologists and reviewing physicians, says Corning-Davis. Ordering physicians, especially heavy referrers, can be targeted in multiple ways including email and in person at staff meetings, so they are aware of the new system and their responsibilities.

Advice from the field

Regardless of the CTRM solution a hospital uses, technology is not a panacea. In fact, the very process of considering a CTRM system will shine a spotlight on inconsistencies and flaws.

CTRM is mission critical; in an ideal deployment, it integrates with other systems so data aren’t housed in a silo. Hospitals should look for a system that can integrate with voice recognition and EMR solutions, says Corning-Davis. Integration streamlines processes and can improve productivity. “CTRM requires good human factors management and a commitment to high-level customer service,” adds Halsted. Many pioneers boosted the success of their project by involving hospital administration including quality improvement and risk management teams from the project’s inception.

It’s also important to remember that the CTRM process extends beyond radiology. “A successful implementation should include announcements to referring physician offices and staff because they receive and handle faxes,” says Corning-Davis. Cain of University of Colorado Hospital recommends new CTRM sites stagger deployment to the target audience. The academic hospital started with inpatient results and followed with outpatient results after three months.

The case for CTRM

IT systems that focus on CTRM can address a number of critical issues. They can streamline and improve results notification to boost patient safety, improve radiologists’ productivity and enhance service to referring physicians and patients. At the same time, systems simplify JC compliance and provide an audit trail that may prove useful in the event of legal disputes about results communication. Training and IT requirements are minimal. The upshot? CTRM systems represent an investment worth making.